EMDR THERAPY PROTOCOL FOR THE

EATING DISORDERS
Natalia Seijo

INTRODUCTION
Based on years of experience with eating disorders (ED), the most appropriate treatment is one that treats the aspects
that give rise to the disorder, rather than focusing on the symptom in isolation. Without a doubt, EMDR therapy
achieves this goal, as it works by going to the root of the trauma, where it all began, and repairing it. When we talk
about trauma in EDs, we are not only talking about traumatic events, but also about attachment and developmental
traumas, which are quite common in these disorders.
The EMDR protocol for eating disorders helps improve the way we understand these disorders and reduces the
recovery time for people who suffer from them. This protocol combines work with trauma, attachment and
dissociation. These three fields are connected at the base of these disorders and must be worked on to achieve
positive long-term results.
The protocol is developed throughout the eight treatment phases and focuses on three basic points:
• Identification and organization of the person's internal world
• Neutralization of defenses
• Processing of different traumas (big T, small t).
The final objective is achieved with the integration of the inner world, through the reprocessing of the traumas that
cause the disorder.

DIAGNOSES

The ICD-10 and eating disorders

In the ICD-10, eating disorders are coded under "Behavioral disorders associated with physiological dysfunctions and
somatic factors." In particular, they are coded in the category “Eating disorders F50”, which includes the following
disorders:

This text has been originally published in English as chapter 3 of the following work:

Seijo, N (2018). EMDR Therapy Protocol for Eating Disorders. In M. Luber (Ed.) Eye Movement Desensitization and Reprocessing
(EMDR) Therapy Scripted Protocols and Summary Sheets. Treating Eating Disorders, Chronic Pain and Maladaptive Self-Care
Behaviors. Springer Publishing Co.

The edition of the original text, as well as its translation into Spanish, has been carried out by Miriam Ramos Morrison.

• F50.0 Anorexia nervosa : Disorder characterized by the presence of deliberate, induced weight loss
 or maintained by the same patient.
• F50.1 Atypical anorexia nervosa : This term should be used for cases in which one or more of
the main features of anorexia nervosa (F50.0), such as amenorrhea or significant weight loss, but which
otherwise present a fairly characteristic clinical picture. This type of patient is more common in consultation
and liaison psychiatry, as well as in primary care. Patients who have all the important symptoms of anorexia
nervosa, but in a mild degree, may also be included here. This term should not be used for eating disorders
that resemble anorexia nervosa but are due to a known somatic etiology.
• F50.2 Bulimia nervosa : Syndrome characterized by repeated episodes of excessive food intake and by
an exaggerated concern for controlling body weight, which leads the patient to adopt extreme measures to
mitigate the weight gain caused by eating food. This term should be restricted to forms of the disorder that
are related to anorexia nervosa by sharing the same psychopathology. The distribution by age and sex is
similar to that of anorexia nervosa, although the age of presentation tends to be slightly later. The disorder
can be considered a sequel to persistent anorexia nervosa (although the opposite sequence can also occur). At
first glance, a previously anorexic patient may appear to be improving as she gains weight and even regains
menstruation if she is female, but then a malignant form of behavior emerges characterized by overeating and
vomiting. Repeated vomiting can lead to electrolyte balance disorders, somatic complications (lithany, cardiac
arrhythmias or muscle weakness) and increased weight loss.
• F50.3 Atypical bulimia nervosa : This term should be used for cases in which one or more of
the main characteristics of bulimia nervosa (F50.2), but otherwise present a fairly typical clinical picture.
Patients often have a normal or even higher than normal weight, but have repeated episodes of excessive
eating followed by vomiting or purging. Partial syndromes accompanied by depressive symptoms are not rare
(if these symptoms meet the guidelines for a depressive disorder, a double diagnosis should be made).
• F50.4 Hyperphagia in other psychological disorders: Excessive intake as a reaction to stressful events and
leading to obesity. Bereavements, accidents, surgical interventions and emotionally stressful events can give
rise to "reactive obesity", especially in patients predisposed to weight gain. Obesity as a cause of psychological
disorders should not be codified here. Obesity can make the patient feel very sensitive about their appearance
and trigger a lack of confidence in interpersonal relationships. The subjective assessment of body dimensions
may be exaggerated. To code obesity as the very cause of psychological disturbance, categories such as F38.-
[other mood (affective) disorders], F41.2 [mixed anxious-depressive disorder], or F48.9 [neurotic disorder
unspecified] should be used. , plus a code of E66.- to indicate the type of obesity.
• F50.5 Vomiting in other psychological disorders : In addition to bulimia nervosa in which vomiting is provoked,
repeated vomiting may occur in dissociative (conversion) disorders (F44.-), in hypochondria (F45.2), in where
vomiting can be one of the many bodily symptoms, and in pregnancy, where emotional factors can contribute
to the appearance of recurrent vomiting and nausea.

RESEARCH STUDIES
This research has studied the effects of "emotional eating" (EE). The study was designed to examine whether treating
AE symptoms with specific EMDR psychotherapy protocols and methods would have a positive effect. Participants
experienced an overall positive change in their eating habits.
The findings and the evaluation of the treatment indicate that there is a positive effect on eating behavior and affective
regulation in the triggering situations that have been defined. This effect is also maintained over time, at least when
checked at 3 and 6 months.
The most effective part of the treatment appears to be the combination of techniques to anchor the sensations in the
physiological and work at a deeper therapeutic level, which provides an understanding of the underlying problems that
ego states work highlights.
The conclusion is that it is possible to demonstrate a positive effect by applying EMDR, and more specifically, the
adjusted DeTUR protocol, in the treatment of EA. The treatment was useful in this case, and since the person is a
typical case of the population of people with EA, it also seems reasonable to conclude that obesity could also be

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reduced when its development is based on emotional avoidance.

MEASURES
These are the measuring instruments used:
• Eating Disorder Inventory-2 (EDI-2) (Garner, 1991)
• Body Attitude Test (BAT) (Probst, Vandereycken, Van Coppenolle, & Vanderlinden, 1995)
• Fear of Negative Evaluation Scale (FNE) (Learly, 1983; Watson & Friend, 1969)

NOTES FOR THE EMDR PROTOCOL SCRIPT

FOR EATING DISORDERS

Phase 1: History Collection

The first thing to keep in mind when starting to work with a patient with AD is that, underneath what the disorder
shows, there is a wounded boy (or girl) waiting to be found and helped. It is a simple guideline that will be important to
remember during treatment.
A good conceptualization of the case will provide a scheme that will guide us towards the established objective. It will
be necessary to gather the person's history to conceptualize the case. We will take notes in the following areas.

General aspects: diagnosis and comorbidity

• Psychopathological evaluation : Diagnosis received by a specialized medical professional. Monitoring and

medical checkups. Analysis of the medical reports that may be provided.
• Associated disorders: Information about those disorders related to AD with which the person may have been
previously diagnosed.

Anamnesis

• General data : Relevant to age, education, profession, marital status, etc.

• Genogram : Graphically compiles the family structure providing information about each member of the
family, as well as the distribution and relationship between them. This multigenerational graphical
representation of the family records information on pathologies and BP of family members up to the second
generation.
• Medical and psychological treatments: Information about the professionals previously consulted. The aspects
of those treatments that have been successful and those that have not. This will provide information on what
to do and what not to do with the client.

History of eating disorder

HISTORY OF WEIGHT

It will be important to ask about current and previous weight and height and determine the person's body mass index
(BMI). Other areas that are important to explore are bowel movements, diets or eating regimens, and physical
symptoms associated with BED, such as lanugo (body hair that covers the body due to weight loss in anorexia nervosa),
Russell signs (calluses that appear with frequency on the knuckles from rubbing the teeth over and over again trying to
provoke vomiting), moon face (inflammation of the parotid glands, located under the jaw, which creates the effect of a
round face in people who purge frequently), sores (sores that appear in the corners of the mouth caused by the

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aggression that occurs in the area when purging).
Some questions, related to amenorrhea and menstrual periods, will be addressed only to girls. The family's reaction to
this issue is important information as sometimes events that happen during this stage in the person's life can be
important targets to work with.

HISTORY OF THE CURRENT EPISODE

The story of the current episode includes gathering all the information about what led to the situation being the way it
is now.
• Moments of restriction : What led the patient to restrict, where it was learned and what was happening
during that time.
• Strange behavior regarding food : It is common for them to lie or omit information about this topic and,
sometimes, this is discovered during the course of therapy. We will focus on obtaining information from the
person or a family member regarding whether they hide food, throw it away, spit it out, or cut it
excessively.

EPISODES OF BINGES AND PURGS

When exploring binge eating, keep in mind that a binge is an excessive intake of food, to the point that a single meal
can contain up to 2,500 calories, which is what a patient can eat for an entire day. Furthermore, this food intake must
be done in a short period of time.
It should be noted that when asked about binge eating, different answers may be given because variations are often
found depending on the BED and how the person perceives the disorder. In cases such as anorexia nervosa (purgative
type), the person will respond that they binge eat. However, the meaning of binge in this TA can be eating an apple,
yogurt, and a cookie, for example. This disorder is based on restriction and anything that goes beyond that can be
considered binge eating.
In the case of binge eating disorder, the binge eating will be like in BN: eating large amounts of food in a short period of
time, as described above. In hyperorexia, where the person binges constantly, it would be something like eating all day,
extending the binge over a long period of time. Either way, it will be important to keep this information in mind to
identify food-related episodes and their triggers.

PURGE

Purging consists of using laxatives, diuretics, etc.

CURRENT TRIGGERS

One of the central points in the treatment of binge eating and vomiting is the stabilization of these compensatory
responses that pose a physical risk and generate dependence. Current triggers refer to those situations that predispose
the patient to binge eating and vomiting, such as loneliness, boredom or sadness.

HOSPITALIZATIONS

This type of trauma has serious consequences for people with AD who have been hospitalized, since these admissions
are difficult due to the limitations to which they are subject.
Hospitalization trauma is caused by the different hospital admissions that people with AD are sometimes forced to
endure. These admissions may be due to extremely low weight, as in anorexia nervosa, and may also be due to chaos
related to binge eating and vomiting in some patients with bulimia nervosa and the risk that this entails. Income can
also be triggered by self-lytic attempts that can occur in times of crisis.
Although the reasons for admission may be different, it is useful to process these hospitalization situations with the

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standard EMDR protocol to help the person recover. In cases of attempted suicide, both moments (what led to the
attempt and the hospitalization itself) must be processed.
Some therapists consider that it can be harmful to process the trauma of hospitalization, since some classic treatments
use the fear of admission as a tool to achieve improvement. In our clinical experience, fear does not seem to be a good
option, as it results in unstable improvements and greater insecurity. The recommendation would be to be able to
relieve your inner world of all those experiences that have left an indelible mark.

food history

HISTORY OF MEAL TIME

Mealtime at home is an important target for reprocessing with EMDR, since these moments end up being conflictive,
generate distress in the person and do not allow improvements until they are worked on.

TIME SPENT IN FRONT OF THE PLATE

This point is important, especially in anorexia nervosa, where the person can spend hours sitting in front of a plate of
food because they are forced to eat what is given to them and internally refuse to do so. Therefore, the person tends
to experience these moments with a lot of suffering, which generates trauma. Each and every memory of this type that
arises will be targeted with the standard EMDR protocol.

PRIMING ATTACHMENT FIGURES

In EDs, it is normal to find attachment figures who feed the person disproportionately, as if signs of affection were
replaced by food. Therefore, the person learns from childhood to eat when they are not hungry and without physical
signs of satiety, thus satisfying the needs of the adult.

Attachment problems

Using this information we can evaluate the attachment style of these patients. We must pay attention to issues such as
parental attachment style, separation or divorce, moving, feeling of being understood and validated, role reversal, etc.

ATTACHMENT TRAUMA

Adverse life experiences associated with the bond with attachment figures tend to occur frequently. You have to ask
about those moments in which there was a lack of validation, support or emotional demonstrations; in which help
from attachment figures was needed, but not received; when she was compared negatively to other people; when
attachment figures showed perfectionism and rigidity; when attachment figures were very critical; when there was a
reversal of roles, etc.

History of trauma and adverse life experiences

On the one hand, trauma can cause a type of traumatic stress disorder with symptoms that last more than a month.
There are various forms of post-traumatic stress disorder, depending on the time of onset and duration of stress
symptoms. In the acute type, the duration of symptoms is 1 to 3 months. In the chronic type, symptoms last more than
3 months. When delayed onset occurs, symptoms appear more than 6 months after the traumatic event.
• Acute, chronic or delayed reactions to traumatic events such as military combat, attacks or natural disasters.

• An anxiety disorder precipitated by an experience of intense fear or horror when exposed to a traumatic
event (especially if life-threatening). The disorder is characterized by recurrent intrusive thoughts or images of
the traumatic event; avoid everything related to the event; a state of hyperactivity; and a decrease in
emotional responsiveness. These symptoms are present for at least a month and the disorder is usually long-
term.

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 • An anxiety disorder that develops in reaction to physical injury or serious mental or emotional distress, such
as military combat, a violent attack, a natural disaster, or other life-threatening events. Having cancer can also
cause post-traumatic stress disorder. Symptoms interfere with daily life and include reliving the event in
nightmares or flashbacks ; avoid people, places and things related to the event; feeling lonely and losing
interest in daily activities; and have trouble concentrating and sleeping.
• Post-traumatic stress disorder (PTSD) is a real illness. PTSD can develop after experiencing or witnessing a
traumatic event, such as a war, hurricane, rape, physical abuse, or a serious accident. PTSD causes a person to
feel stressed and fearful after the danger is over. It affects her life and the people around her. PTSD can cause
problems such as:
• Flashbacks , or feeling like the event is happening again
• Sleep problems or nightmares

• Feeling alone
• Anger explosions
• Feeling worried, guilty, or sad
On the other hand, psychological trauma arising from adverse life experiences is the individual's experience of an
incident, a series of incidents, or a set of lasting conditions in which the individual's ability to integrate his or her
emotional experience (i.e. the ability to be present, understand what is happening, integrate feelings and make sense
of the experience) is overwhelmed.

TRAUMATIC EVENTS

We ask the patient to write down the ten worst trauma-related moments regarding accidents, loss, and grief.

TRAUMA BY HUMILIATION

Trauma due to humiliation must be explored. We ask if you have ever felt humiliated. Humiliation trauma can occur
from looks you received from an adult during childhood or adolescence, or words that were said to you, that made you
feel uncomfortable.

TRAUMA BY BETRAYAL

Betrayal trauma theory (Freyd, 1996, 2001) defines the degree to which a negative event represents a betrayal of trust
and influences how such incidents are processed and remembered.
Betrayal trauma refers to a certain type of trauma, regardless of the reaction to the trauma. Betrayal trauma occurs
when people or institutions – on which the patient depends for survival – violate their trust or well-being, physically
and/or emotionally. Sexual abuse perpetrated by a caregiver is an example of betrayal trauma.

SUBSISTENCE ALLOWANCE

It is common for people who suffer from these disorders to spend most of their lives on a diet, often from early
childhood. Dieting becomes traumatic and is associated with high levels of anxiety, frustration, sadness and a feeling of
helplessness. This really makes the diet impossible.
In the conceptualization of the case, it will be important to collect data on diets. This point will provide information for
when the so-called “diet trauma” is processed. Processing these traumas will help people with an eating disorder
associated with ongoing diet failure to diet effectively without the symptoms of anxiety and distress that often cause
an internal experience of inefficiency.
We must ask questions such as whether the patient is on a diet or follows any dietary regimen; the types of diet you
have tried and their effectiveness; the first or earliest diet; feeding restrictions, if any; possible allergic reactions
confirmed by medical examinations; and the diets that the person has followed throughout their life.

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HIDDEN TRAUMA

Hidden trauma refers to the caregiver's inability to modulate the child's affective dysregulation. In childhood, many
perceived threats derive more from the caregiver's affective cues and accessibility than from the actual level of
physical danger or risk to survival (Schuder & Lyons-Ruth, 2004).

Hidden trauma is very common in TAs, so it is important to be aware of it. It is often difficult to remember them, as
they are subtle events that are usually minimized and are harmful without being overt.
HISTORY OF THE BODY
In this section, we collect precise information about the body, we inquire about the scars that the person may notice
regarding the yo-yo effect (weight gain or loss), important restrictions, etc. We ask detailed questions about the
rejection or lack of acceptance you feel towards your own body and the existence of self-destructive behaviors.

Phase 2: Preparation

This phase provides the structure upon which the rest of the treatment will develop. We will dedicate all the time that
each case requires. The structure of this work focuses on two basic points:

• Identify the internal world of the person with TA

• Neutralize and process defenses.

People who suffer from eating disorders lack childhood experiences and the vast majority are women 1 . They have
always been treated like little adults, forced to assume responsibilities that they should not have assumed. Because
there are external demands greater than they could tolerate, their inner world is overwhelmed and collapses,
triggering the development of parts to protect the system.
It is useful to note that therapeutic work will not focus on eliminating defenses, as this would intensify them, thus
increasing the symptom, sensation or disturbing emotion that contains it. With EMDR therapy, we focus on changing
and neutralizing the defense, while validating the contributions and functions with which it has protected the system.
We must respect the way in which the defenses protect the internal system, although it may not be the most adaptive
way for the person at the present. It is important to remember how adequate the defense was in the past and the fact
that it helped the person survive. Furthermore, we have to take into account that the defenses have a double function
of defense/protection and, at the same time, a resource.

Psychoeducation on the edge of trauma and somatic identifiers

At this point it is important to offer psychoeducation, because by anticipating what may happen, we create an
environment of trust and security. This helps patients understand that they are in a situation where they can be
themselves and work with what arises, trust that they will have support and, above all, that they can maintain an
internal locus of control. –difficult for them to achieve, but extremely important.
We begin by offering psychoeducation on the edge of trauma. Using this concept, we explain that, together with the
person, we will pay attention to a line that we will not cross until they are ready to do so. This line represents the edge
of trauma, which is reached when we begin to touch on traumas or adverse experiences that will need to be processed
so that you can begin to improve and heal the underlying issue. This section of Phase 2 is a step that will help
everything flow properly in Phase 3. We prepare the client by dilating the edge of the trauma , which means that,
respecting this line and helping the person to develop an internal locus of control, we can advance little by little
without risk of deregulation during the sessions, thus generating a secure base .

1 Although the term patient refers to both men and women, throughout the text we will use the feminine term more frequently, given that, as has
been indicated, the majority of patients with this disorder are women.

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We explain that the ideal is to always stay one or two steps from the edge of the trauma, to avoid the emergence of
unpleasant feelings or emotions that could create a negative experience and the risk of rejecting future work for fear
of the pain that could arise.
To know when we are approaching the edge of trauma, we explain somatic identifiers that can give you a clue as to
what is happening. Being able to identify the most common ones will help us see them more clearly. Below are some
examples of somatic identifiers. However, these are indicative, and it will be important to consult with the patient to
find out what each defense actually contains.
• Tension in different parts of the body can reflect the repression of an emotion that wants to come out, but is
blocked.
• Lip biting can be a sign of emotional control. It can happen when the person feels like crying and tries to stop
it.
• Withdrawing eye contact or breaking eye contact at a specific time may indicate that the person does not
want to receive or be seen, or fears exposure.
• Speaking in the second or third person can indicate a lack of integration.
• Tension in the neck may be an attempt to control what is happening during the process and is related to the
feeling of loss of control.
• Feeling drowsy during processing indicates that the patient has surpassed their threshold of tolerance to what
is arising and could be a way of showing that the processing is too intense.
• Headaches during processing may indicate that there is traumatic material that the patient is reluctant to let
out. They could be a sign that a dissociative part is emerging.

Identify the internal world

The internal world can be defined as a set of what Liotti (1999) describes as the different internal representations of
the self. These representations gradually become the basis for the development of autonomous and complex mental
structures that van der Hart (2006) calls dissociative parts.
We must keep in mind that the parts, also called states or representations of the self, develop towards one concept or
another depending on the degree of dissociation that exists. In many cases, parts of the internal world do not become
autonomous. They would be like structures that contain memories of adverse experiences that generate the current
disturbing behaviors associated with food. This is precisely where the professional must enter to process and integrate.
The internal world represents the structure of the personality, the different aspects or parts that make it up. Through
them, people develop their internal experience, their information processing style, their internal world of beliefs, their
management of emotions and their style of interaction with others. Knowing and shaping this structure helps the
therapist and patient to name what has never been named.
When developing the internal world, the therapist must take into account three tools that also function as resources.
1. Validate the patient. Validate the patient throughout the process, as these people often suffer from a lack
of validation from an early age. Therefore, the therapist, in his or her role as “substitute secure
attachment figure,” heals, but also fosters a secure base on which the patient can lean and trust .
2. Promote compassion and understanding: Promote compassion and understanding without judgment, as
they rarely receive compassion from others and sometimes go through different treatments in which they
do not always feel understood. This tool will help the proper development of the therapeutic relationship.
3. Help organize the inner world and its parts: Help organize the inner world and its parts, taking into
account that, in people who suffer from TA, this internal world tends to be chaotic and that is precisely
where we must insist. In the parts section, they will be named and their features described in detail.
Once identified, it will be easy to put together the internal world, as if it were a puzzle. Piece by piece, so that
everything makes sense to the patient and therefore promotes the aforementioned compassion.
Another important step during this phase focuses on psychoeducation, which will be a constant throughout the
treatment. During work with the internal world and the parts, psychoeducation will be essential to provide all the

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information that the person needs to be able to trust the process.

IDENTIFY PARTS, NEUTRALIZE DEFENSES AND ACCESS TRAUMA

At this stage of treatment, psychoeducation will focus on shaping the inner world. This will begin to organize it and
allow us to work with the concept of each part or state as a way to reach and work with the traumas or adverse
experiences contained within them.
We begin by naming the interior parts (Seijo, 2012). Although here we name them feminine, given that the vast
majority of patients with these pathologies are women, they can be adapted to the masculine gender if necessary:
• The girl who never was
• The girl who couldn't grow up
• The pathological criticism
• He I rejected
• He I hidden
• He I chubby
Before starting to develop the parts along with their beliefs, it is necessary to introduce psychoeducation on defenses,
to offer a more visual structure of the inner world and explore therapeutic objectives. This understanding will also
foster compassion.
When we talk about defenses, we are talking about blocking points that prevent the natural flow of therapy or,
specifically, EMDR processing. Work with defenses begins in phase 2 with psychoeducation, which helps the patient
understand the process. The defenses in TAs are one of the key points that must be insisted on, since they can be the
cause of therapeutic failure and/or possible abandonment.
To graphically explain how defenses are distributed in people's inner world, we use the metaphor of the artichoke .
Each layer of this artichoke would be the structure in which one or more parts of the internal world and the defense or
defenses that accompany it are found. This layer, in turn, covers another layer and they all form a structure that
protects the central core, where the most vulnerable part is located. If the clinician understands this structure, it will
facilitate the work that will later be developed in detail during the protocol.
The treatment model develops from the outside to the inside, from the outermost layers to the innermost. By
accessing each layer, a process that follows the Part / Defense / Trauma (PDT) pattern opens. This pattern implies that
when parts of the internal system are activated, defenses are activated. When these defenses are neutralized, they
allow access to the trauma, which is reprocessed with the standard protocol.
The process is similar to "knitting." Each layer takes us to the PDT scheme through which defenses and different
traumas are neutralized and reprocessed. The final result is the integration of the inner world and the normalization of
food and the eating process.
In summary, the process would be as follows:

You access A Activate a The I work with Access to Processing is neutralized

>>> >>> >>> >>> >>> >>>
A layer defense part defending defending The
standard trauma with EMDR
main defenses will be reprocessed with EMDR using the different subprotocols described in the defenses section.
However, the defenses that must be neutralized first are the more subtle ones, such as: the "What if..." defense.
("What if I face it and I can't?"); the defense of "everything is great", pleasing the therapist so as not to go too deep,
etc. If we get to the inner layers too soon, we run the risk of the person feeling threatened and abandoning therapy.
Once these defenses are neutralized, we begin to work with the main ones: lack of awareness of the disease, fear of
improvement, defense of hunger and all those that we will mention later in the protocol and with which we will begin
to work in phase 2. and during the rest of the treatment phases.

The parties/states in TAs and their corresponding beliefs

Each of the previously named parts has its own basic belief, from which other beliefs can be derived. In Phase 2, it is

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helpful to explain each party's beliefs to the person.

THE BELIEF OF “THE GIRL WHO NEVER WAS” OR WORKING WITH CONTROL

This is a very dominant and damaged part that usually generates the most defenses. This part defends the inner world
by exercising control and contains the pain and frustration of having to learn to do things alone. The part holds the
belief that things should be done my way .
Control can be reflected through food, especially in anorexia nervosa. Its origins are the trauma with which the person
will connect and with which we will work with standard protocol to heal the belief.

THE BELIEF OF “THE GIRL WHO COULD NOT GROW UP” OR WORKING WITH GUILT

This part did not go through adequate maturational development and shows some behaviors inappropriate for its age.
This part defends the inner world through guilt . Not feeling seen is connected to the belief that one needs to get sick
to get attention .

THE BELIEF OF THE "HIDDEN SELF" OR WORKING WITH SHAME AND FEAR

This part protects the internal system through shame and fear . The predominant emotion is fear and we must also
work with shame. This part holds the belief that I cannot show up or stand out because if I do, I will be hurt .

THE BELIEF OF “PATHOLOGICAL CRITICISM” (THE PIRANHA) OR WORKING WITH PERFECTIONISM

This is the most hostile and conflictive part of the system, the internal critic or "Piranha" (Seijo, 1999). The patient
immediately recognizes this part as the most active part in her inner world. This part or state defends the inner world
through criticism and the work must focus on perfectionism.
The origins are the traumas that the person connects with and can later work on, using the standard EMDR protocol, to
heal the belief that nothing is ever good enough, which is the basis of this part.2

THE BELIEF OF THE “REJECTED SELF” OR WORKING WITH BODY IMAGE DISTORTION

This part contains the distortion of body image and it is necessary to work at this level. Depending on the patient, this
can range from a negative body image to body dysmorphic disorder. This part holds the belief that I don't want to go
back to who I was .
The rejected self is the dissociative part and the distortion of the image is the defense used by the rejected self. When
we process the rejected self, we are processing both at the same time.

THE BELIEF OF THE “FAT ME” OR WORKING WITH REJECTION AND SUBMISSION

This dissociative part appears most frequently in binge eating disorder, hyporexia, and obesity. In these disorders, it
represents the part of the ego rejected in the present. This means that the body that the person is currently rejecting is
the actual body at the present moment that they have had over the years. (For a more detailed explanation of this
concept, see the complete rejected self protocol.) This part is related to excess weight and remains fixed in the internal
system. It is very resistant to change, generates many defenses – usually somatic – and is covered by layers. It
represents the somatic defense of the hidden self in these disorders.
This part or state defends the inner world through rejection and submission . The feeling of being defective must be
worked on, since the part holds the beliefs that there is no place for me in this world and I am inadequate because I am
fat .

2
Note : A subprotocol for working specifically with Piranha is detailed below.

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0
Psychoeducation on EMDR and the three-pronged protocol

The standard EMDR protocol is a three-pronged protocol: past, present, and future. The three-pronged protocol (past,
present, future) of EMDR is used to reprocess past traumatic experiences, work with present triggers, and address
future concerns in order to bring the patient to the highest level of adaptive responding.

Subprotocol for working with the Piranha: the metaphor for the criticism mechanism

The Piranha metaphor (Seijo, 1999) was developed to help shape and explain one of the most intrusive parts of the
inner world of people who suffer from AD and which makes treatment extremely difficult.
Over the years of working with people who suffer from AD, the name “Piranha” – which emerged one day as a way to
name something harmful inside – became something that fit perfectly with their internal experience, it was quickly
accepted. , and it was effective in helping them. This is how the name was consolidated and became an essential part
of therapeutic work.
Self-criticism is inversely proportional to self-esteem; When one grows, the other decreases. Therefore, when self-
criticism increases over the years due to negative reinforcement from the outside world, it can become pathological.
The negative development of self-criticism can be caused by negative comments, actions, reactions or behaviors from
the family system, social environment, school, peer group, trauma, etc. This, combined with the lack of validation that
would have provided adequate compensation, turns self-criticism into an enemy within. Something similar to an
autoimmune disease on a psychological level: it defends and protects the inner world by attacking it.
The Piranha part is the first “voice” that people with AD identify. They describe an intense, harsh and very critical voice
that causes great distress and makes hurtful comments about their physique, their diet, their behavior and their
personality. Comparison and humiliation are examples of what this part generates in the internal experience, that is,
how the person perceives it internally.

This part tends to show itself in an adverse way. However, its function, like that of the rest of the parts, is to protect
the inner world. It is not a negative part, but quite the opposite; It is the way he learned to defend the inner world and
that has worked until now, even though things are no longer the same as before. When the person experiences the
Piranha internally as a very harmful voice, they often have difficulty understanding its protective function.
Consequently, we must find a way for it to learn to protect in a more adaptive and appropriate way. As clinicians, we
must keep this in mind so that we are not confused by the patient's point of view.

PSYCHOEDUCATION ABOUT PIRANHA

Psychoeducation about Piranha helps patients understand the protective function and identify how this part acts and
how it communicates within the internal system. Thus the person learns to recognize the origin of distorted critical
messages, which so destabilize their inner world.
We must achieve certain objectives:

• Protective function : It is important to take into account the protective function that this part has played in
the inner world so far, as it develops through the internalization of the negative comments that have been
received from the most critical attachment figures. Therefore, the Piranha imitates the learned negative
comments. The person may have trouble grasping this concept, so the most important thing is to
understand that Piranha avoids emotional pain by imitating the attachment figure whose comments were
hurtful. The basic idea is that if internal self-criticism is more intense, external criticism will be less painful.
Once the person becomes aware of this protective function, thoughts about this part change and it
becomes normal. The person understands better that when the part appears it is because they are trying to
heal. The goal is for the Piranha to transform into healthy self-criticism and help regulate the inner world.
To do this, we will guide the person to find where they learned to protect themselves in this way, eliciting
memories that we will work with using standard protocol.

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 • Differentiate the internal from the external . Differentiate between what belongs to the person and what
belongs to others. We must explain that those needs not met by others are really the needs that the person
is not meeting for themselves. To work on this, we use current situations that act as triggers, so we activate
the PDT pattern that will lead us to the memories that we will process with the standard protocol. These
memories represent where the person learned not to distinguish that what is internal and external are
different. Differentiation is an internal experience that people with AD have not learned adequately in their
development. Using the membrane concept helps them clarify it and develop it appropriately.

• Establish a safe place indoors . Develop an inner safe place that restores trust and security in your own
internal world. When the Piranha becomes a healthy and regulating part, a more reliable inner space will be
generated, which will increase self-respect and the ability to make better decisions.

• Differentiate healthy criticism from Piranha . We identify the different ways in which the Piranha
communicates, while we differentiate the function of healthy criticism from unhealthy and pathological
criticism (Piranha). The Piranha communicates through cognitive distortions. Some of the strategies used
are negative thinking habits, which cause the person to interpret reality in an unrealistic way. It makes her
see herself as she is not, both physically, emotionally and psychologically, which causes unnecessary
suffering.
The most common distortions are described below. We must explain this to the patient so that they can begin to
identify them:

• Personalization . Through it, the person appropriates situations and behaviors that are not
related to it.

• Polarized thinking . This distortion generates a thought process that resembles binary language. Through this
distortion, reality is seen in "black and white."

• Filtered out . To explain the filtering, we continue with the metaphor of the telescope that describes in a
way
simple how this distortion works.

THE METAPHOR OF THE TELESCOPE

Patients can easily understand the Piranha mechanism – how it transforms reality – so that what has been distorted is
replaced and they can have a more adequate experience of reality.
Being able to identify when and how this part appears makes the person aware of repairing the distortions of the
Piranha. The clinical work will consist of helping to transform these distortions or thoughts into healthy beliefs.

INTERVENTION

Once the person knows the strategies used by this part and can identify them, the objective will be to neutralize them.
To do this, we must ask questions focused on creating doubts about the internal experience of that part, which is
experienced as something real.
When you identify, understand and are able to manage this part, it is possible to get to the origin, which is connected
to the person's history: Who does this part resemble or imitate?
For this part of the work, a very valid instrument is a diary in which you can take notes about the Piranha's messages.
This helps to work with these messages during the sessions. What did the Piranha feed on? And where did you learn to
do it that way? By doing so, patients delve deeper into the internal experience, identifying the causes of that internal
information that they had not been aware of until now.

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Sometimes this intervention creates defenses that provoke different reactions among therapists:

• Some professionals decide to be rescuers in order to convince the patient. However, the professional gets
"lost" and wears himself out looking for a way to do it.
• The other reaction is to assume that the patient is a lost cause , the therapist feels frustrated and the person
confirms what they bring.
The correct guideline will be to help the patient identify which part is activated and observe what triggers it. This
begins the work related to neutralizing the defense to work with the part and everything else that is triggered, just as is
done with the PDT pattern. We also validate the difficulties that the patient has encountered when seeking help and
how positive it is to express it.
The therapist, in turn, will internally identify all those emotions and reactions that may be part of the transference
generated by the therapist-patient relationship. We must not enter into conflict; Thus, the defense may be neutralized
and not reinforced as part of the problem that leads them to be incapable of working on what really generates the
disorder.

Subprotocols to work with defenses

These protocols are used as a stabilization tool, so we include them at the end of Phase 2. However, we will use them
as needed during treatment. If one of these defenses appears and blocks processing, we need to step back and process
it using these different subprotocols, so we can continue moving forward in our work.
DEFENSE OF LACK OF AWARENESS OF THE DISEASE

Patients deny having a TA, since they do not identify with those who suffer from this disease. As a justification for the
defense, they usually use those characteristics that differentiate them from the TA. They usually feel uncomfortable or
upset when talking about the TA and display a closed and uncooperative attitude, which often causes frustration in the
therapist. Under this defense there is fear of improvement.

SOMATIC DEFENSES

Somatic defenses are symptoms, sensations, physical reactions, gestures or somatizations through which the body
communicates. They are activated during the therapeutic process when the internal system is compromised, usually by
emotional pain or a threatening trigger. As clinicians, we must pay attention to each part of the body that shows
tension, contraction, pressure, tremors, tingling, muscle weakness, restlessness, tiredness, pain, burning, etc.
Regardless, each patient has their own somatic language and being able to clarify this helps increase awareness.

DEFENSE OF ALEXITHYMIA

Alexithymia is characterized by difficulty verbalizing emotions, recognizing them and using them as internal signals. It is
part of the dissociative experience and generates a somatosensory deficit. The goal of working with alexithymia is to
reconnect with the body. The underlying belief is: If I don't feel, I won't suffer.

DEFENSE OF HUNGER

This sensation is similar to hunger, but it is not physical hunger. The role of this defense is to cover up the underlying
emotion. Patients believe that they cannot face this emotion because they feel that they have no resources. They eat
to calm the feeling of hunger and cover up the emotion that they consider intolerable.
By working with this defense, patients will be able to differentiate between the hunger defense and true physical
hunger. By doing so, the patient increases their sense of control, which is crucial when this defense is present.

DEFENSE OF FEAR OF IMPROVEMENT

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It is the fear that appears as a defense against the possibility of improving and the therapy being effective. This defense
is very common in AD, and in AN it is one of the main defenses that prevents the development of treatment from the
beginning.

• Anorexy . With anorexia, the possibility of getting better can lead to fear of gaining weight. The belief
underlying is: I am only worth it if I am thin , so the disorder ensures thinness. Improving is associated with
gaining weight and therefore being defective and unworthy.

• Binge eating disorder . With binge eating disorder, defense tends to show itself through the fear that if the
person "lets the food go," they will lose the only safe haven that provides comfort and the element that
allows them to connect to a secure base. Therefore, fear of improvement will appear to sabotage the therapy.
Binge eating has a "curtain" function, which covers what hurts or bothers the person, so as not to see it.
Therefore, if there is improvement, the fear lies in seeing too much.
When several defenses appear at once, we must remember that the internal world feels threatened. In these cases, we
must respect the defense and find which part is blocking, through this defense. We move on to work with the
part/defense/trauma (PDT) system, until we reach the point where the person has learned it and can connect with the
trauma, which we will process using the standard protocol.

Phase 3: Evaluation

Phase 3 begins when T ot trauma memories arise while working with the PDT schema. That's when we use the
standard protocol.
In this phase, the belief that defines each of the different parts is a crucial aspect. For example, "the girl who never
was" has beliefs related to things being done my way and there are no limits but mine , which are based on control.
Another peculiarity to take into account during this phase is alexithymia. This dissociative type defense – characterized
by difficulty recognizing one's own emotions and those of other people – tends to be present in EDs, especially in
disorders based on avoidant attachment, such as anorexia nervosa and psychogenic vomiting. Therefore, these
patients will find it difficult to describe their feelings. Because of this difficulty, the person will usually not give us
adequate information about emotions or feelings, so it will not always be possible to evaluate SUD. Instead, we will
typically proceed to directly access the CN and process without the SUD. The patient is asked to focus on any sensation
or signal in the body, no matter how small, and we begin to process it. As integration increases, alexithymia decreases.

Dianas

TAKING TARGET ON FOOD

We use the following difficult moments as targets:

• Sitting at the table, that is, being in front of the plate of food
• think about food

TARGET ON CURRENT TRIGGERS

We use the following difficult moments as targets for current triggers:

• The uncontrollable cravings to eat right before binge eating or purging begins.
• Anticipation of binge eating and vomiting
• Anxiety, boredom and sadness
• Other triggers that result in binge eating and purging, which are patient-specific

TARGET THE HOSPITALIZATION TRAUMA

We use the following difficult moments as targets for hospitalization trauma:

• Nasogastric tube that TA patients must wear at all times

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 • The most difficult moments of hospitalization.
• Eat in the common dining rooms.

TARGET THE TRAUMA OF DIETS

We used the following worst difficult moments as targets for diet trauma:
• The oldest and most difficult moments related to diets.
• The effort and suffering when they are on a diet.
TARGET TRAUMA, ADVERSE LIFE EXPERIENCES, AND ATTACHMENT ISSUES

We process the traumas indicated by the patient in Phase 1 that have to do with events related to trauma or
attachment problems.

Betrayal trauma

In betrayal trauma, the person cannot trust themselves or others. We use the following as targets for betrayal trauma:

• Distrust itself.
• Events through which they learned to distrust.

Hidden trauma

We use the following as targets for hidden traumas:

• Hurtful and subtle messages with double meanings, as well as verbal manipulations identified by the
patient
• Gestures and silences that make the patient feel ignored

Phase 4: Desensitization

One of the peculiarities of this phase is somatic processing. This type of processing lacks images and thoughts. During
processing, the patient tends to repeat "nothing comes to me" over and over again. However, if we pay attention to
the body, we can identify the changes that are happening. This type of processing will be explained in more detail in
the section on somatic defenses.
During processing, it will be important to take into account dual attention, since depending on the different degrees of
dissociation that accompany these disorders, the patient may confuse the past and the present during reprocessing
and enter a dissociative state. To prevent this from happening, you must keep one foot in the present and the other in
the past, remembering that both somatic memories that can appear in the form of physical sensations and memories
that appear on a cognitive level are part of a past that already exists. It is gone. According to the PAI model, both types
of memories are dysfunctionally stored information; something we are trying to reorganize properly with EMDR.
Another characteristic to take into account during this phase is that the interweaving can be both cognitive and
somatic (the latter will be explained in the somatic defenses section). Among the cognitive interweaves, the one we
will use the most is psychoeducation: brief information that completes what is missing in internal experience. Another
useful interweaving will be the validation of one's own experience during reprocessing, as previously indicated in phase
2.

Phase 5: Installation

It is necessary to reorganize the processing, due to the dispersion of information that may appear during reprocessing.

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Therefore, when we return to the memory, we focus again on a specific neural network, which allows us to process all
the associated memories. This facilitates, at the same time, the integration of the inner world.

Phase 6: Body Scan

As with stage 3, alexithymia can cause difficulties when checking the body. Therefore, we will value the information
that the person provides us, even if it is not precise. As the integration of the patient's inner world increases, the way
the client feels their body and the information they give us about it will also improve.

Phase 7: Closure

In this phase, processing is reinforced and new ideas are recognized. Here we spend some time on the new material
that has emerged, reinforcing it by increasing awareness of the new ideas and adding bilateral stimulation, which will
help with integration.
Therefore, the unhealthy relationship with food begins to change, so it can no longer be used to cover up frustrations,
fears or traumatic memories. Once processing is complete, the food will no longer have its pathological function and
will therefore simply be food.
When the different traumas and defenses are processed, the person becomes increasingly aware of how these are
related to eating problems. As treatment develops, the disorder will also improve.
As the processing of traumatic events evolves, the integration of the parts will increase and the voices will decrease in
intensity or disappear. At this point, we must be aware of what has been called "duel for the parties." In this process,
after the integration of the parts, the person feels sad because of the inner silence. There is additional sadness
associated with realizing all the lost time, which will also need to be processed using standard procedures.

Phase 8: Reassessment

In the next session, the target from the previous session is re-evaluated. We must bear in mind that, if the SUD has
increased compared to the previous session, it is likely that the memory is associated with other memory channels.
Often, what seemed to be a very clear target in the session can be divided into several targets in the next session.

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 EMDR THERAPY PROTOCOL SCRIPT
FOR EATING DISORDERS

Phase 1: History Collection

This section includes the specific questions that we will ask the patient.

General aspects: Diagnosis and comorbidity

We ask about the psychopathological evaluation:

We say: Has a specialist given you a diagnosis for what is happening to you?

We ask about associated disorders:

We say: Have you received any other diagnosis in the past?

Anamnesis

We ask general information:

We say: Now I will collect information about personal data such as age, education, marital status, etc.

We make a genogram.

We say: To get an outline of your family, I'm going to do what we call a genogram, which means I'm going to
ask you about your parents, siblings, grandparents, etc.

We ask about medical and psychological treatments.

We say: Have you previously received psychological and medical treatment?

If the answer is affirmative, we say: What has worked about these treatments and what has not worked?

History of eating disorder

HISTORY OF WEIGHT

We say: Now I'll ask you some questions about your height and weight, so we can calculate your BMI.
We say: How tall are you?

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 We say: What is your current weight?

We say: What has been your maximum weight

We say: What has been your minimum weight?

We say: What are your bowel movements like? Did you have or do you have constipation? What do you think
is the cause?

We say: Are you following any type of diet or eating regimen?

If the patient's answer is affirmative, we ask the name of the professional who monitors their diet.
We say: Please tell me the name of the professional / dietitian / nutritionist who monitors your diet.
We say: I'm going to ask you about some symptoms associated with eating disorders in case you recognize
any.

If the patient suffers from AN :

We say: Have you noticed if you have more hair on your body, hair that appears in places where there was no
hair before? It is called lanugo.

We say: Have you noticed if the palms of your hands have an unusual orange color?

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 We say: Have you noticed if you have excess energy despite losing weight?

We say: Have you noticed colder than usual, especially in your hands and feet?

We say: Have you noticed dizziness or that your heart feels different?

One of the important criteria of AN is alexithymia or the inability to identify and describe one's own emotions or
identify or feel the emotions of others, so it will be important to ask the following question:
We say: Have you noticed if you feel your emotions less, as if you have lost sensitivity?
We say: Have you noticed if you feel differently from other people around you?

We say: Have you ever been surprised to observe that when you feel you do it differently than other people?
Have you asked yourself why?

We say: Have you ever considered yourself a cold person?

One of the clearest symptoms of AN is a lack of awareness of the disease or denial of it, so it is important to ask about
it.
We say: Do you know what is happening to you? That is, are you aware of your illness?

If the answer is no, we say: What do you think is the reason you are here today?

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If the answer is affirmative, we say: What do you think the disorder is?

If the patient suffers from BN :

We say: How many binges do you binge a day?

We say: Do you vomit after the binge or do you compensate in another way?
We say: I'm going to ask you to show me your hands to see if you have calluses on your knuckles.

We say: Have you noticed if you have petechiae under your eyes? They are like little red dots of blood.

We say: Have you noticed if your heart beats faster or your heartbeats are irregular, as if you had tachycardia?

We say: Have you noticed if the shape of your chin has changed?

We say: Have you noticed if you have small painful marks on the corners of your mouth that sometimes bleed?

If the patient suffers from binge eating disorder:

We say: Have you noticed swelling in the body?

We say: Have you noticed abdominal pain?

We say: Have you noticed pain in your legs?

Only for girls:

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 We say: It is important to have information about your menstruation, so I will ask you some questions about it.

We say: When did you first get your period? How did your family react to your first menstrual period?

We say: Have you ever had your period go away for a while? When did it happen

We say: Are you currently on your period? Is it regular every month

CURRENT EPISODE STORY

We say: When was the first or most significant time that you remember starting to pay attention to food in a
way other than just eating?

We say: What was happening at that time in your life? And with the food?

We say: Where did you learn to do it that way?

We say: What is your way of eating today?

If the patient does not give us enough information, we will complete this information with the family.
We say: Can you tell me the peculiarities of your way of eating?

RESTRICTION EPISODES

We say: I would like to know more about those moments of restriction. Could you describe those moments at
the table during meals?

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 We say: Do you feel more discomfort? Are the parties more activated and does the conflict increase?

We say: Do you feel like you dissociate during meals?

We say: After eating, do you feel guilty for having eaten?

We say: Do you feel more distrustful during meals?

EPISODES OF BINGES AND PURGS

We say: Have you had or do you have episodes in which you have or do you binge eat?

We say: What are your binge eating like?

We say: How long have you been giving them?

We say: How often do you binge?

We say: Does binge eating have a function for you? Do you give them to yourself because you feel full or
empty, sad, alone, etc.?

We say: When was the first time you remember binge eating?

We say: What are the earliest or most significant memories associated with vomiting?

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 We say: What was going on in your life at that time?

CURRENT TRIGGERS

We say: The general precipitating factors for binge eating are generally those times when you feel sadness,
boredom, or anxiety. Can you identify with any of these?

We say: In addition to these general triggers, there may also be specific ones that trigger the episodes. What
do you think are the current situations that lead you to binge, vomit, or compensate in some other way that I
haven't asked you about yet?
We say: Could you describe where you learned to do this?

PURGE

We say: Now I would like to ask you if you compensate for binge eating with vomiting.

We say: Do you use any type of medication, such as diuretics or laxatives?

HOSPITALIZATIONS

We say: Have you ever been hospitalized for your eating problems?

We say: Have you been to a medical facility due to the disorder even if you were not admitted, for example, to
the emergency room or to your family doctor?

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history of food

FOOD HISTORY

We say: Let's talk about meals at home. Who sat at the table during meals?

We say: What are meals like for you now?

We say: What are or were your family's eating habits like? Do they usually eat quickly or slowly? Are there
members of your family who eat differently?
We say: Who cooks or used to cook at home?

We say: What are your eating habits like at home? In your opinion, is your diet balanced?

We say: Is there anyone at home who is or has ever been on a diet?

TIME SPENT IN FRONT OF THE PLATE

We say: How much time do you spend on meals?

We say: Do you spend a lot of time at the plate or do you finish quickly?

PRIMERING ATTACHMENT FIGURES

We say: Is there someone in your family who represents what is called a feeding figure, someone in your
family who has fed you too much? For example, someone who fed you even when you told them you weren't
hungry?

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 If the answer is affirmative, we say: How did this feeding figure feed you?

We say: When did he do it?

Attachment problems

We say: I would like to know what your relationship is like with your parents or the attachment figures you
grew up with and to do so I will ask you some questions about it. Describe to me what your father is like in the
link. Is he a loving and close person or rather cold and distant?

We say: What is the relationship between your parents like?

We say: What relationship do you have and have you had with each of them?

We say: Describe to me what your mother is like in the relationship. Are you affectionate or rather the
opposite?

We say: Are your parents married or divorced?

If they are divorced, we say: What is or has been the relationship with their respective partners?

ATTACHMENT TRAUMA

We say: Have you always lived in the same place or have you lived in different places during your childhood or
adolescence?

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We say: Who has been the person by whom you have felt most validated in your life? Who is the person you
have felt most understood by in your life?
We say: Who has been the person by whom you have felt the least understood and validated in your life?

We say: What would you have needed to feel understood and validated?

We say: Who has been the person who has given you the most love?

We say: Who has been the person who has made you feel safest?

We say: What is your father's typical expression?

We say: What is your mother's typical expression?

We say: Have you ever felt like your parents' mother or father, as if you had had a role that did not belong to
you?

We say: Could you tell me the times you remember when your parents, or people who represented affection
and security, made you feel that you were not valuable?

We say: Have you felt that you were not offered comfort when you needed it?
We say: Have you felt that they have been rigid or perfectionistic with you, forcing you to meet high
standards?

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 We say: Has anyone ever compared you to other people, leaving you in the worst position

We say: Have you felt that you were not comforted when you needed it?

Trauma history

We say: We are now going to collect all the information related to those adverse events or experiences that
may have marked you in some way. We will have to work with them throughout therapy so that they stop
affecting you in the way they have been doing until now.

TRAUMATIC EVENTS

We say: Have you suffered any type of accident that has marked you emotionally or physically?

We say: Have you suffered the loss of a loved person who has been important and hard for you?

We say: Have you suffered any significant loss in your life that has caused you emotional pain?

TRAUMA BY HUMILIATION

We say: Let's now explore the adverse experiences that you have suffered in your life, which may have been
traumatic in some way for you.
We say: I would like to know if you have ever felt any abuse of power that has made you feel humiliated or
that you have had to submit in some way.

TRAUMA BY BETRAYAL

We say: Have you ever felt betrayed by someone?

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 We say: Have you suffered sexual abuse, touching or inappropriate behavior in that sense?

We say: Have you ever suffered looks that made you feel uncomfortable?

TRAUMA FROM DIETS

We say: How many times have you been on a diet?

We say: When were you on a diet for the first time and how old were you?

We say: Whose idea was it to put you on a diet?

We say: What has been the worst moment of all the diets you have done?
We say: How would you define the worst moment of going on a diet?

We say: Was it necessary to do the diet? Because?

We say: What happens inside you at mealtime?

HIDDEN TRAUMA

We say: Have you felt that you had to calm down or regulate yourself or, on the contrary, has there been
someone for you who has helped you do it?

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 If the answer is that there was no one, we say: When did you realize that you didn't feel seen by your parents
or the people who took care of you when you needed to calm down and no one was there for you?

We say: Have you ever felt like you needed your parents or the people who cared for you to see you and meet
your needs, but that wasn't the case?

We say: Have you felt that you have been understood and validated on an emotional level when you felt sad or
angry?

HISTORY OF THE BODY

We say: What comes to you when you think about the body?
We say: What words or adjectives would you use to define it?

We say: Are there any physical marks of TA that worry you, such as scars or stretch marks from weight change,
loose skin, etc.?

We say: Have you received negative comments about your body?

If the answer is affirmative, we say: By whom

We say: Have you ever caused harm to your body by feeling upset or by channeling frustration

If the answer is affirmative, we must find out about the type of self-destructive behavior.

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 We say: What did you do?

Phase 2: Preparation

Introduction to the preparation phase

We say: Let's start organizing the work that we will do throughout the sessions so that you can understand it
and trust the process. You and I need to be a team so you don't feel like you're alone in this . First we will
identify the aspects or parts of you that make up your internal world. Then we will neutralize the defenses that
may arise and that will warn us that we have to stop and check. This way we will know that we are going at
the right pace and not too fast, especially with things in your life or food that may be difficult for you to deal
with. For that we will respect your defenses, since they will provide us with valuable information. We will
neutralize them with a resource that helps your internal world and the parts that live in it and we will continue
to move forward little by little with our work. The goal is for you to feel better and better. There may be
moments that are a little less simple than others, but the important thing is that from those moments you get
reinforcement that helps us move forward.

Psychoeducation on the edge of trauma and somatic identifiers

We say: The first thing we need is to be able to understand how your internal world works. To do this, we are
going to see what identifiers are going to show us that we are approaching the edge of trauma, which is the
line that establishes how far we can go at each moment in the therapy work. We will always stay one or two
steps away from this edge of trauma so that you feel safe in the process and can also feel internal control and
know that everything is okay.
To know when we approach this edge of trauma, let's see what sensations or emotions you usually feel when
you become deregulated. For example, it could be that you get more sensations of not feeling your body, or
sensations of suddenly being very tired, that you feel sleepy, or perhaps the sensation of not being present or
that your heart is racing. It may be sensations of this type or similar ones that tell us that we are approaching
the edge. If so, tell me and what we will do is stop and introduce a resource that will help us make you feel
calm and know that everything is okay.

Identify the internal world

We say: The structure of this next phase of our work focuses on two basic points: identifying the parts of your
inner world and the defenses that normally protect these parts.
The internal world represents your personality and could be explained with the simile of an orchestra. An
orchestra is made up of musicians led by a conductor. When the musicians play in unison and follow the

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 conductor, the orchestra sounds phenomenal. However, when one of the musicians becomes wayward and
refuses to play, wants to impersonate the conductor, or wants to play another instrument that does not
belong to him, it will cause the orchestra to not function well.
The same thing happens in your internal world; When aspects or parts of you want to perform functions that
do not correspond to them, things do not work well in there. So our job will be to relocate every aspect of you
that is out of place. As we work, you will get to know every part of yourself and this will make you understand
much better what is happening to you and will help you get out of the eating disorder you suffer from.
Throughout the process, it is important to validate the patient, promote compassion through understanding,
and help organize the internal world and its chaotic parts, naming and describing them in detail.
We say: I understand that it is being difficult for you to understand what is happening inside you, since you
probably feel a certain chaos that on many occasions does not allow you to identify what is happening. So that
you can understand it better, I am going to present to you the different states or parts into which your internal
world is divided, so that you can order it.

IDENTIFY PARTS, NEUTRALIZE DEFENSES AND ACCESS TRAUMA

We say: To begin organizing your internal world, we will begin by naming the parts and explaining what
function and belief they have within you. These are the parts or states that I will explain to you in detail in a
few minutes:
• The girl who never was
• The girl who couldn't grow up
• The pathological criticism
• The rejected self
• The hidden self
• The chubby me
We say: So that you can understand better, these states or internal parts that I have named generate
defenses. Defenses are all those internal experiences that prevent us from continuing processing at a given
moment. These internal experiences can be emotions, thoughts, sensations or movements that arise from the
body. Each part or state generates its own defenses that we will identify in order to neutralize them and
continue moving forward with our work, little by little and always trusting in the process.

artichoke metaphor

We say: The inner world could be represented using the metaphor of the artichoke. This helps us see all the
layers that cover the inner world, as a way of protecting its most vulnerable part. When working with EMDR
therapy, each of these layers contains the traumas, adverse experiences, and defenses that may arise. We will
gradually process each of these layers, until we get to the heart of the artichoke and repair what needs to be
repaired. This is always done with great care, respecting the internal world and, above all, trusting the
process.
Once we start working with parts, you will see that each one has specific defenses, but so that you can
understand how this plays out based on the artichoke metaphor, I will explain it to you in more detail.
The treatment model for TAs develops from the outside in, starting in the outermost layers and moving
inward. Each time we access a layer, we open a process that follows the pattern: part, defense, trauma, also
called the PDT system. When parts of the internal system are activated, defenses are activated. Defenses are
how the parties learned to protect the system. The fear of coming into contact with what is difficult to
remember activates defenses to avoid pain. By softening these defenses, it is possible to access adverse or
traumatic life experiences and reprocess these memories with the standard EMDR protocol. For example, if the
“girl who never was” part is activated and the control defense appears, using the PDT system, we will ask
ourselves: “Where did this part of you learn to control in this way?” or "Where did this part of you learn to

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 protect yourself through control?" This question will give us access to the memories contained in the part,
which will be processed.

The parties/states in TAs and their corresponding beliefs

It is important to educate patients about the parts/states in TAs and their corresponding beliefs:
We say: Each of the previously named parts has its own basic belief, from which other beliefs can be derived.
As we talk about each part, I'll want to know how much of this fits your experience.
We say: When we work with the parts/defense/trauma (PDT) system, I am going to ask you to identify the
triggers that activate this system. These could be a current situation, a personal relationship, or an event that
threatens the inner world. For each party, this threat will cause a different defense to emerge. The origin of
this defense and its corresponding belief is the trauma that you connect with when we explore where you
learned to defend your internal world in each of the ways .

THE BELIEF OF “THE GIRL WHO NEVER WAS” OR WORKING WITH CONTROL

We briefly explain this part to the person, indicating the belief that accompanies it.
We say: The girl who never was" contains the pain and frustration of having to learn to do things alone. It
represents the self-sufficient child, who has been forced to grow up quickly and become an "adult" in
childhood. He has learned to self-regulate and have self-control through food and does things his own way.
This part, which learned to defend the internal system through control, has the belief that "things should be
done my way."
We say: Could you tell me how much of this fits with your experience?

We explore triggers.
We say: What makes this part of you activate?

We continue to explore this part in more depth.

We say: Tell me about this part. How old are you?

We say: When did this part begin to exist?

We say: Where did you learn to feel this way

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We then explore where the person learned to defend their internal world by exercising control.
We say: Where did this part learn to defend you through control?

THE BELIEF OF “THE GIRL WHO COULD NOT GROW UP” OR WORKING WITH GUILT

We briefly explain this part to the person, indicating the belief that accompanies it.
We say: "The girl who could not grow up" did not achieve adequate maturational development and shows
inappropriate behavior for her age. This is a lost girl who doesn't know if she's allowed to speak or not, and
through food, she has found a way to be seen. This part defends the inner world through guilt, believing that
"if I am not seen it is my fault." The main belief is "I need to get sick to get attention."
We say: Could you tell me how much of this fits with your experience?

We explore triggers.
We say: What makes this part of you activate?

We continue to explore this part in more depth.

We say: Tell me about this part. How old are you?

We say: When did this part begin to exist?

We say: Where did you learn to feel this way

We then explore where the person learned to defend their internal world through guilt.
We say: Where did this part learn to defend yourself through guilt?

THE BELIEF OF THE "HIDDEN SELF" OR WORKING WITH SHAME AND FEAR

We briefly explain this part to the person, indicating the belief that accompanies it.
We say: The "hidden self" protects the internal system by hiding, not exposing or showing itself, since every

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 time it did this in the past, things became threatening and even dangerous. Staying in the shadows ends up
being safer. This part develops early in life and somatizes what cannot be expressed in any other way. This
part, which learned to defend the internal system through shame, holds the belief that "I can't show up or
stand out because if I do, I will be hurt."
We say: Could you tell me how much of this fits with your experience?

We explore triggers.
We say: What makes this part of you activate?

We continue to explore this part in more depth.

We say: Tell me about this part. How old are you?

We say: When did this part begin to exist?

We say: Where did you learn to feel this way

We then explore where the person learned to defend their internal world through shame.
We say: Where did this part learn to defend yourself through shame?

THE BELIEF OF “PATHOLOGICAL CRITICISM” (THE PIRANHA) OR WORKING WITH PERFECTIONISM

We briefly explain this part to the person, indicating the belief that accompanies it.
We say: The Piranha is the inner critic, always judging and blocking your self-esteem, filtering reality and
letting in only the negative perspective. This part imitates, in the inner world, those who criticized and judged
you as a child in real life, which led to constant comparison with others. This part, which learned to defend the
internal system through criticism, holds the belief that "nothing is ever good enough."
We say: Could you tell me how much of this fits with your experience?

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We explore triggers.
We say: What makes this part of you activate?

We continue to explore this part in more depth.

We say: Tell me about this part. How old are you?

We say: When did this part begin to exist?

We say: Where did you learn to feel this way

We then explore where the person learned to defend their internal world through criticism.
We say: Where did the Piranha learn to defend yourself through criticism?

THE BELIEF OF THE “REJECTED SELF” OR WORKING WITH BODY IMAGE DISTORTION

We briefly explain this part to the person, indicating the belief that accompanies it.

We say: The 'rejected self' is a part of you, past or present, that you reject and are ashamed of. This part may
contain feelings of disgust or contempt, and may have been there over the years as a printed image of what
you never want to be again, and through which you see yourself when you look in the mirror.

We say: Could you tell me how much of this fits with your experience?
We explore triggers.
We say: What makes this part of you activate?

We continue to explore this part in more depth.

We say: Tell me about this part. How old are you?

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 We say: When did this part begin to exist?

We say: Where did you learn to feel this way

We then explore where the person learned to feel rejected.

We say: What is the oldest or most significant memory in which you have felt or seen yourself rejected?

THE BELIEF OF THE “FAT ME” OR WORKING WITH REJECTION AND SUBMISSION

We briefly explain this part to the person, indicating the belief that accompanies it.
We say: The "chubby self" meets unmet needs through the body. Weight gain is the protective somatic defense
of this part, so the person either hides beneath this self, or takes up more space in the world because they do
not feel seen. This part, which has learned to defend the internal system through rejection and submission,
holds the beliefs that "There is no place for me in this world" and "I am inadequate because I am fat . "
We say: Could you tell me how much of this fits with your experience?
We explore triggers.
We say: What makes this part of you activate?

We continue to explore this part in more depth.

We say: Tell me about this part. How old are you?

We say: When did this part begin to exist?

We say: Have you ever felt unseen or have you ever felt like there is no place in the world for you?

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 We say: Where did you learn to feel this way

We then explore where the person learned to defend their internal world through gaining weight.
We say: Where did your chubby self learn to defend yourself through gaining weight?

Psychoeducation on EMDR and the three-pronged protocol

Before entering Phase 3, or before applying any of the sub-protocols, we offer a brief explanation about EMDR:
We say: When trauma occurs, it appears to be blocked in the nervous system with the original image, sounds,
thoughts and emotions. The eye movements we use in EMDR appear to unblock the nervous system and allow
the brain to process the experience. This may be what happens during REM sleep: eye movements may help
process unconscious material. It is important to note that it is your own brain that is going to do the healing
and that you are the one that is in control. When we process following the three-pronged protocol, we are
talking about the fact that once the experiences of the past, which affect your life in the present, are
processed, they will no longer affect you and will not disturb you in the future.
Subprotocol for working with the Piranha: the metaphor for the criticism mechanism

Once the Piranha is identified, as well as the place where the patient learned to develop this part or state, it will be
necessary to stabilize the inner world. When we begin this work, this part is likely to have a destabilizing effect due to
the adverse experiences or traumas it is connected to. For this reason, we will first start working with this subprotocol,
which was developed specifically for this part.
We say: Now I would like to start working with this part of you, the most critical part of your inner world,
which we call Piranha because of how it behaves inside you. This does not mean that it is a negative part – it is
not the case at all, although it sometimes seems that way – but the way it appears can be quite aggressive.

PSYCHOEDUCATION ABOUT PIRANHA

We say: We will start by getting to know this part better and offering you psychoeducation on how it behaves
in your inner world and the function it has.

First, we explain the protective function of this part.

We say: The Piranha avoids emotional pain by imitating the attachment figure whose comments were hurtful.
The basic idea is that if internal self-criticism is more intense, external criticism will be less painful. The goal is
for the Piranha to transform into healthy self-criticism and help regulate the inner world .

Second, we teach you to differentiate the internal worlds from the external ones through the concept of "membrane."

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 We say: Those needs not met by others are really the needs that you are not meeting for yourself. To
differentiate what is internal from what is external, I would like you to imagine a membrane that divides the
internal and external world. By doing this, you can now realize that what is inside your membrane belongs to
you and that what is outside the membrane belongs to the external world.

Third, we help patients identify the different communication styles of the internal critic.
We say: Healthy criticism has the functions of regulating how you conceive of yourself; provide a point of view
based on reality; and regulate self-esteem and self-concept so that you develop a certain acceptance.
However, when criticism becomes unhealthy and becomes the Piranha part, it creates internal communication
that is harmful to you.

To better understand the Piranha's harmful communication, we explain cognitive distortions.

We say: To explain personalization distortion, we will use a real-life situation. Imagine that you meet a friend
and, during the conversation, he tells you that he is tired. If the Piranha uses this distortion at that moment,
you'll probably start to think you're boring your friend. Focusing on this doesn't give you the option to think
that he may be tired for a variety of reasons, but you being bored is more than likely not one of them.

We say: One way to understand the distortion of polarized thinking could be knowing that something white
does not become black because it has a stain. There are many colors and many ranges between them, and
white is just another color.

We say: Filtering is another cognitive distortion that this part uses as a way to transform internal experience. It
could be described as if the Piranha puts a filter in front of your senses. This is how you filter reality. Negative
information would filter in and out, even though the positive information is still there. It is as if in addition to
filtering it, it recorded it and saved it for another more convenient time. Let's pay attention to how it happens.
For example, you go somewhere or talk to someone and, when the situation has passed, the Piranha reminds
you how inappropriate you were. You may also associate this event with other past situations when you were
as inappropriate as in the previous situation. This will make you feel bad and generate feelings of being
inappropriate, which damages your self-esteem.
We say: Do you have any questions or comments about what I just explained to you?

THE METAPHOR OF THE TELESCOPE

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The telescope metaphor can be explained through the following visualization exercise.
We say: You are going to allow me to explain to you, through a metaphor, how this Piranha part works in your
mind. Imagine a telescope pointing towards the stars. How do you see them?

We say: Okay, now imagine what happens if you turn the telescope and look the other way.

We say: Okay, you see them further away. Now, imagine the telescope again and see what happens now if you
change the lens of the telescope to one that is scratched.
We say: You are doing very well. Imagine the telescope again and see what happens if you change the lens for
one that is scratched and also stained with grease.

We say: You would see blurry spots, right? Well, you know what? This is how the Piranha makes you see reality
most of the time. That's one of the reasons why we have to change the scratched and stained lens to one that
is just scratched, and once you are able to perceive something other than stains, we can exchange it for a
crystal clear lens, so you can tell me that you see the stars clearly, although distant. Then we will rotate the
telescope and you will be able to see them completely clear.

We say: To achieve this, it will be necessary to work with the distortions of the Piranha and be able to
recognize them. This will allow you to differentiate what is yours from what is external and thus change the
lenses. It is not a party or state that we have to fight against. On the contrary, it is a part of you that we will
have to help heal because it has become unhealthy.

INTERVENTION

We help differentiate the Piranha in the following way:

We say: All the negative thoughts that come to you in relation to yourself and make you suffer come from the
Piranha. People don't hurt themselves for free, so we know something isn't right and we need to help it heal so
you can see yourself for who you really are and accept yourself.
To neutralize the stratagems used by the Piranha and obtain information about beliefs:
We say: What thoughts has this part shown you?

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We say: What proof do you have that what he has shown you is true?
We say: If that thought came to someone you cared about, would you think the same thing?

We say: What alternative interpretations are there?

We say: What kind of distortion is it?

We say: How does that thought make you feel?

We say: If that thought were true, what is the worst that could happen?

We say: What do you think Piranha is trying to hide with what he shows you?

We say: If you could say something to the Piranha about how he acted in that situation, what would you say?

We say: What other options would you suggest to him regarding how he could act towards you so that he
doesn't make you feel this way?

We say: Could you describe where your Piranha learned to defend yourself through criticism?
We say: Let's take one of these memories and treat it with the standard EMDR protocol so that this part of you
can integrate and become healthy criticism. We will work with the oldest or most significant memory that
came to you when I asked you where your Piranha learned to defend you through criticism.

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Subprotocols to work with defenses

These subprotocols should be used as necessary throughout the treatment process, when defenses block the
continuity of the process.

DEFENSE OF LACK OF AWARENESS OF THE DISEASE

We look for the exceptions, those times when they noticed there was some kind of problem with the food.

We say: Think about a time when you realized something was happening with food in your life.

We do EBL.3
We explore the role of advocacy following the work of Jim Knipe (2005):
We say: What is the good thing about not identifying with TA?

We say: What is wrong with not identifying with the TA

SOMATIC DEFENSES

One of the places where trauma resides is the body. Trauma is stored at a somatic level. By working on the area of the
body where it has been stored, we can help process and release all the traumatic material it contains. The dissociative
parts also contain and show themselves through somatic defenses. The work here is to give voice to that defense that
blocks internal experience and identify its function.

We say: Allow yourself to notice what is happening in the body right now that is preventing us from continuing
to process. Describe to me what you feel and where you feel it in your body.

Then we should do a modified reprocessing, focusing on a sensation, emotion, or pain instead of the usual image of the
standard procedure and asking about the negative belief.
We say: Focus on the sensation you are noticing in the body. If that sensation, pain, or bodily experience that is
appearing could be expressed in words, what words would they be?

3 Note : We are not going to ask for SUD, since, in many cases, patients also have alexithymia, so they do not initially recognize sensations or
emotions.

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We do EBL.

We say: What does it say _____ (name the sensation/pain/body experience) about you?

Or we say: Yes _________ (name the sensation / pain / bodily experience) had words, what would I say to you?
Check the SUD.
We say: On a scale of 0 to 10, where 0 would be no disturbance or neutral and 10 would be the highest
disturbance you can imagine, how much disturbance do you feel now?
0 1 2 3 4 5 6 7 8 9 10
(no disturbance) (maximum disturbance)
We do EBL.

If the patient cannot find the belief, we take the somatic reaction and evaluate it from 0 to 10 and, only with those two
elements, the SUD and the somatic reaction, we do bilateral stimulation.
We say: Focus on the physical reaction you are noticing and on a scale of 0 to 10, where 0 would be no
disturbance or neutral and 10 would be the highest disturbance you can imagine, how intense do you feel it
now?
0 1 2 3 4 5 6 7 8 9 10
(no intensity) (maximum intensity)
We do EBL.

We continue to process the sensations until they are no longer present and the disturbance has reached zero.

DEFENSE OF ALEXITHYMIA

We ask patients to describe how they experience "not feeling."

We say: Could you describe what you notice when you have the experience of not feeling?
The defense begins to deactivate by asking the following:
We say: What happens inside you when __________ (indicate what you experience when you don't feel)?

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

We do EBL.

Once the defense is lowered, we explore the memories that generated this belief and work with them with the
standard EMDR protocol.
We say: When do you remember having to start not feeling to protect yourself?

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

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Once the defense is disabled, the patient will be able to begin reconnecting.4

DEFENSE OF HUNGER

We help the patient differentiate hunger defense from physical hunger.

We say: Do you feel this sensation as physical hunger because you are really hungry or is it something that looks
like hunger, but is not?

We say: How do you feel this and where do you feel it?

We say: This sensation is what we call hunger defense. See if you can identify the emotion he is hiding.

We say: In what situations does the defense of hunger appear?

We say: What happens when the defense appears?

We say: If this defense were not there, what would happen?

We ask the patient to connect with the sensation of hunger and measure its intensity.
We say: Notice this feeling of hunger. On a scale of 0 to 10, where 0 would be no feeling of hunger or neutral and
10 would be the most hungry feeling you can imagine, how much disturbance do you feel now?
0 1 2 3 4 5 6 7 8 9 10
(no feeling of hunger or neutral) (maximum feeling of hunger)
We do EBL.

DEFENSE OF FEAR OF IMPROVEMENT

We ask the patient to describe what he or she is noticing inside.

We say: It seems that there is something that is blocking the flow of the therapy. Could you check inside and
notice what's happening? Can you describe it to me?

4
Note : Please remember that when doing Phase 3 during the standard EMDR protocol, emotions and SUD level may not be obtainable.

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Then we named it: "fear of improvement."
We say: This defense is called fear of improvement and it has to do with being afraid of the possibility of
improving and that the therapy will be effective. Could you check inside and tell me if this is for you?

We ask the patient, once again, to locate that fear of improvement in the body, and then we begin to process and
collect information about what arises after the rounds of bilateral stimulation. Sometimes they are not able to describe
where they feel the fear because people who suffer from anorexia may have some degree of alexithymia.
We say: Where do you notice fear in your body?

We say: Notice this fear. On a scale of 0 to 10, where 0 is no fear or neutral and 10 is the most fear you can
imagine, how afraid are you now?
0 1 2 3 4 5 6 7 8 9 10
(no fear) (maximum fear)
We do three or four rounds of EBL to neutralize the defense and introduce the belief with which that fear of
improvement can be related.
For anorexia :
We say: This fear is usually related to gaining weight and the internal belief that "I am only valuable if I am
thin."

We ask the patient to focus on that belief while we do bilateral stimulation to see how true it is.
We say: Could you focus on the belief that “I am only valuable if I am thin”?
We do EBL.

This belief is usually true, so we must look for its origin:

We say: Where did you learn that you are only valuable if you are thin?

We obtain a memory or set of memories, which leads us to the trauma that will be processed in Phase 3 using the
standard EMDR protocol. The patient may say that he or she does not feel that the belief is true. In that case, you may
be in denial and unable to see or recognize the belief for the same reason: fear of improvement. This defense may
require several sessions until the original trauma is processed.
For bulimia and binge eating disorder :
We say: This fear is usually related to stopping eating and the internal belief that "without food I have no
support."
We ask the patient to focus on that belief while we do bilateral stimulation to see how true it is.
We say: Could you focus on the belief that “without food I have no support”?
We do EBL.

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This belief is usually true, so we must look for its origin.
We say: Where did you learn that without food you have no support?

We obtain a memory or set of memories, which leads us to the trauma that will be processed in Phase 3 using the
standard EMDR protocol.
Other aspects to explore in both bulimia and binge eating disorder are the following:
LACK OF CONTROL WITH FOOD

We say: In binge eating disorder, one of the first steps in treatment is to stabilize the state you are in regarding
food. For this, we will first spend time on the problem of lack of control in this regard. So, when you see
yourself at the table in front of food, how much do you feel in control when it comes to food?

We say: If that lack of control said something about you, what would it say?

The answer usually reveals the belief.

We say: When was the first or earliest time you felt this lack of control along with words (we name the above
belief)?

Using the standard EMDR protocol, we select those memories that represent a lack of control so that the patient can
regain the feeling of being in control.

THE IMPULSE TO EAT

We target the exact moment when the feeling of desperation with food appeared and then apply EBL. The intention is
to reduce the intensity of the impulse.
We say: Let's focus on the sensations that represent the impulse you feel when you are about to binge. Let's
work with this. When you think about the moment you are about to binge, focus on the exact moment that
represents the impulse to go get food. How do you feel that impulse in your body and what sensation
represents it?

We do EBL.

We say: Thank you for focusing on this situation where you feel the urge to eat and notice this urge to eat that

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 you feel. And on a scale of 0 to 10, where 0 is no urge to eat or neutral and 10 is the biggest urge you can
imagine, how much craving do you feel right now?
0 1 2 3 4 5 6 7 8 9 10
(no impulse) (maximum impulse)
We do EBL.

THE URGENT TO VOMIT

We say: Let's focus on the sensations that represent the impulse you feel when you are about to vomit. Let's
work with this. When you think about the moment you are about to vomit, where do you feel that urge in your
body?

We do EBL.

We say: Thank you for focusing on this situation where you feel the urge to vomit and notice this urge to vomit.
And on a scale of 0 to 10, where 0 is no or neutral urge to vomit and 10 is the strongest urge you can imagine,
how much of an urge to vomit do you feel right now?
0 1 2 3 4 5 6 7 8 9 10
(no impulse) (maximum impulse)
We do EBL.

Phase 3: Evaluation

Target selection

IMAGE

We select a target image (static frame) from the memory.

We say: Which image represents the worst part of this incident now?

Obtain negative cognition (NC) and positive cognition (PC)

NEGATIVE COGNITION (CN)

We say: What words best correspond to that image, that express your negative belief about yourself now?

POSITIVE COGNITION (PC)

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 We say: When you remember the image of the incident, what would you like to believe about yourself now ?

VALIDITY OF COGNITION (VOC)

We say: When you go to the image of the incident, how believable do you feel the words ____________________
(we repeat positive cognition) on a scale of 1 to 7, where 1 feels completely false and 7 feels completely true?
1 2 3 4 5 6 7
(completely false) (completely true)

Identify the emotion, SUD level and location on the body

EMOTIONS

We say: When you bring to your mind the image (or incident) and the words _________________ (we name
negative cognition) , what emotions do you feel now?

SUBJECTIVE DISTURBANCE UNITS (SUD)

We say: On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can
imagine, how much disturbance do you feel now?
0 1 2 3 4 5 6 7 8 9 10
(no disturbance) (maximum disturbance)

LOCATION OF BODY SENSATION

We say: Where do you feel it (the disturbance) in the body

Phase 4: Desensitization

We apply the standard EMDR protocol for all targets

We say: Go to the image and the words ___________________(we repeat the CN) and notice where you feel it
in the
body. Now continue ___________________ (we indicate the EBL modality).
This procedure must be repeated until the SUD equals 0. Then positive cognition sets in. Each traumatic event
associated with the problem that is not reprocessed during the normal course of the first target should be processed
using the standard protocol until the SUD reaches an ecological 1 or 0 and positive cognition is installed.

We say: When you go back to the original incident, on a scale of 0 to 10, where 0 is no disturbance or neutral
and 10 is the most disturbance you can imagine, how much disturbance do you feel now?
0 1 2 3 4 5 6 7 8 9 10

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 (no disturbance) (maximum disturbance)
If the SUD is 1 or more, the options are as follows:
We say: Look at the incident, as it is now stored in your head. Which aspect is most disturbing?

Or we say: What is it in the image that is causing the ______________________ (we indicate the level of SUD)
Do you see

We say: Focus on that aspect. Okay, do you have it? Go with it.
We do rounds of eye movements or other EBL until the SUD = 0.

Phase 5: installation

Install the CP

We say: When you return to the incident, how true do you feel the words _____________________ (we repeat
the
positive cognition) on a scale of 1 to 7, where 1 feels completely false and 7 feels completely true?
1 2 3 4 5 6 7
(completely false) (completely true)
We say: Think about the incident and hold it together with the words ________ (we repeat the CP). Get on with
it.
We continue this procedure until the VoC is 7.

Phase 6: Body Scan

We say: Close your eyes and keep the memory in mind. Then, direct your attention to different parts of the
entire body, from the head down. If you find tension, tightness, or any unusual sensations at any point, tell me.
If the patient indicates any sensation, we do EBL.
If it is a positive or comfortable feeling, EBL is used to strengthen the positive feelings.
If it is a feeling of discomfort, it is processed again until the unpleasant sensation disappears. Finally, we must check
the VoC.
We say: When you go back to the incident, how believable do you find the words _______________ (we repeat
the
positive cognition) on a scale of 1 to 7, where 1 feels completely false and 7 feels completely true?
1 2 3 4 5 6 7
(completely false) (completely true)

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Check all other targets (past memories and current triggers)

See Phase 1: History Collection: We determine an appropriate and feasible treatment goal and decide whether it is still
necessary to reprocess these experiences (SUD on recall > 0).
We say: Let's check the next target on your list _____________________________ (we name the target). In a
scale from 0 to 10, where 0 is no disturbance or neutral and 10 is the most disturbance you can imagine, how
much disturbance do you feel now?
0 1 2 3 4 5 6 7 8 9 10
(no disturbance) (maximum disturbance)
If the SUD > 0, we continue the procedure and start from Phase 8: Reassessment.

Installing the future template

If all targets are processed (Phase 1: History Collection: Determine an appropriate and feasible goal for treatment) as
well as current triggers, patients may still have to anticipate future situations in which previous phobic stimuli are
present. (for example, in the situation of being in front of the plate at the table) and need to interact with these
stimuli. To prepare for this, you are asked to mentally move forward in time until you identify a specific mental image
of a typical future situation in which your fear was activated before this session. This may be a situation that patients
often avoid out of fear or a situation that, until now, they have not been able to enter or suffer without fear.
We say: Okay, we've reprocessed all the targets we needed that were on your list. Now let's anticipate what
might happen when you are faced with ______________________________________ (we indicate the object
or
the situation that causes anxiety) . Think about a time in the future and identify a mental image or photograph
of a typical situation that would have made you afraid before our work together. It would?

We say: I would like you to imagine yourself dealing effectively with ___________________________________
(we name the fear trigger) in the future. Focus on the image, tell yourself, “I can handle it,” notice the
sensations associated with this future scene, and follow my fingers (or any other EBL).
We say: To what extent do you think you are able to handle this situation (VoC) on a scale of 1 to 7, where 1
feels completely false and 7 feels completely true?
1 2 3 4 5 6 7
(completely false) (completely true)
We continue this procedure (instructions and VoC scoring) until the future template is sufficiently installed (VoC = 7).
If there is a blockage – meaning that even after 10 or more installation rounds, the VoC is still less than 7 – it is because
there are more targets to identify and address. We must use the standard EMDR protocol to work on these targets,
before continuing with the template. In addition, we evaluate whether patients need new information, resources or
skills to be able to comfortably visualize the future scene they are going to face and we present it to them.
We say: What would you need to feel confident in handling the situation?

Or we say: What would you be missing when it comes to handling this situation?

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Checking the film

After incorporating a positive template for future actions, we ask the patient to close her eyes and mentally play the
movie of the future situation.
We say: This time, I would like you to imagine yourself in the future. Close your eyes and mentally play the
movie from beginning to end. Imagine yourself facing the challenges that come your way. Notice what you are
seeing, thinking, feeling and experiencing in the body. As you play through this movie, let me know if you hit
any sticking points. If it happens, just open your eyes and let me know. If not, let me know when you've
finished the entire movie.
If the patient reaches a blockage point and opens her eyes, it is a signal for us to give her the following instructions:
We say: Tell yourself “I can handle it” and follow my fingers (or another form of EBL).

The mental movie is repeated until the patient can see it in its entirety without distress.
We say: Please repeat the movie until you can watch the whole thing without anxiety.

In order to have some indication of her self-efficacy, we asked the patient to rate her experience on a VoC scale from 1
to 7. This procedural step can provide us with information about the extent to which the objectives are met.
We say: When you go back to the incident, how believable do the words feel on a scale of 1 to 7, where 1 feels
completely false and 7 feels completely true?
1 2 3 4 5 6 7
(completely false) (completely true)
If the patient can mentally play through the movie from start to finish with a feeling of confidence and satisfaction, we
ask her to watch it again, do EBL, and install the “I can handle it” PC. In a way, this film is installed as a template for the
future.
We say: Play the movie one more time from beginning to end and tell yourself, "I can handle it." Get on with it.

Phase 7: Closure

Incomplete session

The session is incomplete when there is still unresolved material:

• If there is still discomfort or if the SUD is greater than 1

• VOC score is less than 6
• Negative sensations persist in the body scan
• If the SUD is greater than 1, we skip phases 5 and 6
We congratulate the patient for the work done and evaluate the need to use stabilization and relaxation techniques,

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containment and/or sensory orientation exercises.
We say: We have almost run out of time and we are going to have to stop soon. You have done a very good
job and I really appreciate the effort you have put in. How do you feel?

We say: We're not going to do the positive cognition installation or the body scan because there's still raw
material. However, we will do a containment exercise.
We say: I would like us to do a relaxation exercise before stopping. You want to do _______________________
(suggest a type of relaxation, such as a safe place) ?

Full session

Once stabilized, we say: Things may come to you or they may not. If they come to you, great. Write them
down and we might work on it like a target next time. You can use a journal to write down triggers, images,
thoughts or cognitions, emotions and sensations; You can rate them on our scale from 0 to 10, where 0 is no
disturbance or neutral and 10 is the worst disturbance imaginable. Also write down positive experiences. If
new memories, dreams or situations come to you that bother you, just take a good snapshot. It is not
necessary to give many details. Just write down enough to remember so we can work on it next time. The
same goes for any dream or positive situation. If negative feelings arise, try not to make too much of them.
Remember, it's just old stuff. Just write them down for next time. Then do the safe place exercise to release as
much disturbance as possible. Even if nothing shows up, be sure to use the safe place every day and call me if
you need to.

Phase 8: Reassessment

Evaluate what remains to be done.

We say: What have you been noticing since our last session

We say: What are the current symptoms, if any, that you have been noticing?

We say: What kind of progress have you noticed, especially in terms of homework?

We say: When you think about the target we were working with last time, on a scale of 0 to 10, where 0 is no

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 disturbance or neutral and 10 is the highest disturbance you can imagine, how much disturbance do you feel
now?
0 1 2 3 4 5 6 7 8 9 10
(no disturbance) (maximum disturbance)
If you have increased the disturbance level, these reverbs need to be worked on.

Reprocessing an incomplete target

If the target was incomplete in the previous session, we return to it and continue reprocessing.
We say: Go back to the incident ______(we indicate the incident) that we worked with in the previous session.
What's coming to you?

We say: What thoughts come to you

We say: What emotions come to you

We say: What physical sensations come to you

Access the baseline

We say: On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can
imagine, how much disturbance do you feel now?
0 1 2 3 4 5 6 7 8 9 10
(no disturbance) (maximum disturbance)
We continue reprocessing until phases 4, 5 and 6 are complete. This is when the patient has reached SUDs = 0 and VOC
= 7 and the body scan does not present any disturbance.
If the target is complete, we recommend continuing with the treatment plan and reprocessing more targets.

SUMMARY
This chapter explains the EMDR therapy protocol for eating disorders, detailing everything the clinician must take into
account to advance step by step through the eight phases of treatment. The goal is to process the traumas and adverse
experiences that form the basis of these disorders; work layer by layer from the outside in, as the artichoke metaphor
explains. Each and every layer contains a part, a defense, and a trauma or adverse life experience, as specified in the
Part/Defense/Trauma system. Once the party is named and the defense is identified, it is possible to reach the target
event/trauma and process it with the standard EMDR protocol. As these events are processed, patients integrate the
parts of their internal world. This will be directly reflected in an improvement in your relationship with food and, as a
result, the disorder will improve.

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REFERENCES

Brown, S. (2010). EMDR Solutions II: For Depression, Eating Disorders, Performance, and More. Journal of EMDR
Practice and Research , 4(2), 98-99.
Halvgaard, K. (2015). Single Case Study: Does EMDR Psychotherapy Work on Emotional Eating? Journal of EMDR
Practice and Research , 9(4), 188-197.
Hudson, J. I., Chase, E. A., & Pope, H. G., Jr. (1998). Eye Movement Desensitization and Reprocessing in Eating
Disorders: Caution Against Premature Acceptance. International Journal of Eating Disorders , 23(1), 1-5.

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